One of the most exciting achievements in medicine in the past decade has been the elucidation of the structure and physiological characteristics of releasing or inhibiting fac- tors for each of the classical hormones of the anterior pituitary. The treatment of propoxyphene overdose involves: (1) gastric emptying, (2) activated charcoal, and (3) naloxone. 5, May 1984 CONTENTS icientific Articles To Comfort Always: Strategies for Pain Management in Terminal Cancer Linda M. Kohl 283 The Clinical Management of Sore Throat: A Comparison of Three Ambulatory Settings Michael S. Poe 302 Allied Health Professionals An Update on Physician Assistants: The N. The move to reduce medical care costs has accentuated the importance of these efforts. Bodger GF, Jordan WS Jr: d/ness In fhe Home A Study af 25.000 Illnesses in a Group of Cleveland Families- Clevelond, The Press of Wes T- ern Reserve University, 1964 3 Komoroff AL, Aronson MD, Pass TM, Ervin CT, Branch WT Jr: Serologic evidence of chtomydiol and mycoplasmal phoryngitis in adults. Hohn EO: Comporo- live effects of penicillin, aureomycinond terromy- cin on streptococcol tonsililis and phoryngitis. Most health outhorities agree that attention to balanced diet and adequate caloric intake eliminates the need for supplemental vitamins for most people. Market St., Box 487, Hertford 27944 (1986) Vice-Councilor James M. This clinic is the state's only special migrant clinic that operates full-time year- round. Table 1 Federal and State Migrant Clinics Surveyed Federal Tri-County Community Healtti Center, Newton Grove fi/ligrant Family Health Service, Hendersonville State Albemarle North (Camden, Currituck, Pasquotank Counties) Carteret County Healtti Department Greene Health Care, Inc.

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Information on both is accumulating so rapidly that a lengthy review would be inappropriate and quickly out of date. however, to provide readers with a short summary of im- portant initial observations and a tentative assessment of the potential role of these hormones in clinical diagnosis and therapy. In addition to providing respiratory support, the "big gun" used in the treatment of propoxyphene overdose is nalox- one (Narcan), a very effective, safe, narcotic antagonist. This article reviews the actions of the different vitamins, the disease states associated with their deficiencies, the recommended doily intake of these nutrients, and identifies those indi- viduals more prone to require vita- min supplementation. The results suggest important factors and programs that should be considered when providing migrant health care.

Both have been isolated and characterized only within the past two years. University of Nortti Carolina School of Medicine, Chapel Hill 27514. There are some good animal studies that suggest that repeated doses of activated charcoal could be quite beneficial in the treatment of this problem, i.e., repeated doses of 1 00-200 grams of activated charcoal , administered via N-G tube, in the first few hours post ingestion. NC SCRAP METAL "Southern National's quick-decision policy gi\es us terrific purchasing leverage. And their courtesy means a lot to me." Jack Miklas Oinie [^ Miklas Tile &Aulo Senice. NC TRANSMISSIONS "Working with Southern Nationa gives me a ver\' comfortable feeling. so instead of wasting m\ time shopping |^ the market for rates and sen'ices. Mis- conceptions surrounding vitamin use are both plentiful and varied. These include the two federally funded migrant health care clinics discussed above and nine health departments or clinics which offer migrant health programs (table 1).

Attempts over the past 20 years to purify GRF from animal hypothalami, however, have been unsuccessful, primarily because of the minute quantities present. This substance remains an ever increasingly popular OTC analgesic-antipyretic; new brands are still appearing of the drug alone, e.g.. and in a host of "cold remedies," "pain killers" (often associated with aspirin), "sinus medicines." etc. World- wide, vitamin A deficiency is a lead- ing cause of blindness in childhood. High doses of retinol should only be token under close medical supervision. Occasionally, a vitamin K deficiency is seen in o per- son who takes antibiotics that may inhibit the organisms responsible for vitamin K synthesis. Hodgson 375 Physicians' Forum Is There a Doctor Glut? Linfors 379 Features for Patients Stepped Care for Diabetes Mellitus George J. Blythe 403 Ethics Human Experimentation: The Ethical Dilemma John B. 510 7th Ave., W,, Hendersonville 28739 First Vice-President F. Results Data on outpatient encounters, referrals, outreach, and evening clinics are summarized in table 2.

A long awaited breakthrough came in November 1982, when investigators at the University of Virginia reported the isolation of a peptide with GH releasing activity from a human pancreatic tumor. The addition of cyanide decreased the usage of at least one brand of acetaminophen for a while over a year ago. Pregnant women must take in enough retinol to ovoid fetal mal- formations. Vitamin A is stored in the body and high doses can lead to a toxic state with throbbing headaches, nausea, vomiting, dizzi- ness, insomnia, and night sweats. However, this is only seen if dietary intake is insuffi- cient. As men- tioned earlier, vitamin C is necessary to prevent scurvy. Phones: Raleigh 828-9334 o Statewide 1-800-662-791 North Carolina MEDICAL JOURNAL for doctors and their patients volume 45, no. June 1984 CONTENTS Scientific Articles Renal Dialysis for Kidney Failure in North Carolina: History, Practice, and Lessons Robert A. Graham 405 NCMS Auxiliary Inaugural Address Linda P. Box 10707, Raleigh 27605 Presidenl-Elect Kenneth E. There was a total of 12,003 outpatient encounters reported. 6 Table 2 Services Offered and Number of Migrants Served by Federal and State Clinics 1982 Outpatient Encounters Referrals Outreach Evening Clinic Clinic # % of total # % of OP # % of OP # % of OP Federal TCCHC 5,165 43.0 1,636 31.7 4,328 83.8 not offered Hendersonville 4,000 33.3 — — conducted 160 4.0 Subtotal 9,165 76.3 1,636 3,500 — 1,011 — Prospect Hill 950 8.0 27 2.8 1,500 158 not offered Surry 74 0.6 78 105 conducted not offered Wilson 840 7.0 442 52.6 500 59.5 not offered Yadkin 422 3.5 127 30.1 conducted not offered Subtotal 2,838 23.7 87.5 1,781 14.8 County programs seized migrant outpatients through eve- ning clinics instead of during general c Unic hours unless needs were emergent.

In this article we will review the current knowledge relating to the two most recently discovered factors, corti- cotropin-releasing factor, or CRF, and growth hormone- releasing factor, or GRF. Activated charcoal works quite nicely here to bind the ingested propoxyphene remaining after gastric emptying. The time and mone\' I sav by working with Southern National i a big help. References 1- Gognon R, De Lozier J, Mc Lemore T: The National Ambulatory Medical Care Survey, Urited States, 1979 Summory, U. Deponmen T of Heol Th and Human Services, Public Heolth Service, Publ. Holmberg SD, Faich GA: Streptococcol phoryngitis and ocute rheumottc fever in Rhode Island. Again, very few of these people will derive much benefit from such therapy. Raleigh 27611 Councilors and Vice-Councilors — 1984-1985 First District Robert E. The TCCHC utilizes two nurse practitioners and one full-time physician while * Personal aommunication with Ms. This paper presents the results of a survey of eleven migrant health care programs in the state.

The names of the known factors and some of their major effects are summarized in table 1 . The use of gastric emptying in propoxyphene overdose can be very tricky; because of the propensity for coma, seizures and respiratory depression soon after an overdose, very "cautious" gastric lavage would seem to be the wiser course. NC Itsit TIRES "It's not easy these days for the small businessman to keep his inde pendence. NC SOUTHERN NATIONAL BANM \m can tc U \ c \ ant \ otir busixics: aans BB (te i NJorth Carolina 4EDICAL JOURNAL )r doctors and their patients lover illustration by Ernest Craige, M. In this climate the patient must remain in close communication with primary care physicians, so that mutually satisfactory management of sore throats in 1984 can be attained. Pediatrics 1953,11:7-13, 5 Report of the Eighty-Sixth Ross Conference on Pediatric Research, Monogement of Phoryngitis in on Era of Declining Rheumotrc Fever, 1984 6. Another segment of the American public seeks vitamin therapy for re- lief or cure of such i I Inesses as cancer, heart disease, and arthritis. The MFHS serves mainly Henderson, Polk, Burke, Haywood, and Rutherford counties, and migrants from northern South Carolina. As in many migrant clinics, nurse practi- tioners provide a majority of the care. (Greene County) Hyde County Health Department Nash County Health Department Prospect Hill Clinic (Caswell, Alamance Counties) Surry County Health Department Wilson County Health Department Yadkin County Health Department the MFHS employs three nurse practitioners and one part- time physician.

H00367801P ^^m u NWERsiii of N^Ri H mm SEP 29 1984 HEALTH SCIENCES LIBRARY HHBI^H^ ^B ui^^-mj^,j,,^WMUA»jjj,l H«^^i^fli J^ft,^fif Jff! Although CRF appears to have a much longer half-life than most of the other hypothalamic releasing factors when given to man," its use in place of cheaper and more easily adminis- tered adrenal glucocorticoids appears improbable in the near future. Serum and urine levels do not relate well to the amount of drug ingested or the degree of poisoning. Healthy people do not need to have their diet supplemented by vitamins. Generally speaking, vitamins can be grouped into two distinct catego- ries: (1) fat-soluble vitamins which include A, D, E and K and (2) water- soluble vitamins B, C, niacin, and folic acid. Claims for megodose vitomin E ther- apy improving circulatory disorders, heart diseases, and athletic and sex- ual performance are largely un- founded. Green leafy vege- tables, dairy products, ond fruits con- stitute the major dietary sources of the fot-soluble vitamin K. Albemarle, Nash, and Yadkin clinics could only provide a partial breakdown.

fljfffg^ 1 Official Journal of the NORTH CAROLINA MEDICAL SOCIETY January 1984, Volume 45, No. In this early stage of our knowledge, extrapi- tuitary effects of potential therapeutic value cannot be ruled out. von Welder K: Corticotropin releasing factor stimulation test in normal controls and patients with disturb- ances of the hypolhalamo-pituitarv-adrenal axis, Klin Wochenschr 1985-1491. Pharmaceutically speaking, the development and use of Darvon may not represent our finest hour. Other vitamins such as pantothenic acid, biotin, choline, and the bioflavinoids will not be dis- cussed OS their nutritional signifi- conce is not as well understood. But most vitamin K is produced by microorgan- isms in the intestine. Lamar Callaway 392 Learning Without Words Black Dermographism Lester J. Neelon 398 Toxic Encounters From Grandma to Galen: Boric Acid Poisoning Ronald B. Six of nine clinics, one federal and five state, performing outreach were able to provide numbers of migrants screened.

''* The patient, a 21-year-old woman, presented with January 1984, NCMJ signs and symptoms of acromegaly. Vale W': Pituitary microadenomas causing Cushings disease respond to corticotropin releasing factor, J Clin Endocrinol Metab 1917-1019. but now it seems that these non-aspirin products are being used more than ever. Since vitamin A is a fat- soluble vitamin, most fatty foods con- tain it; fish, organ meats, cream, but- ter, eggs and milk ore all excellent sources. A promising yet largely investiga- tional use of vitamin A derivatives hos been in the prevention of certain cancers and skin disorders. Symptoms of an overabundance of vitamin D include anorexia, weakness, nausea, vogue aches, weight loss, hypertension, anemia, and possible irreversible kidney failure. Other possible inhibitors of vitamin K absorption include liver disease, malabsorptive syndromes, and drugs such as cholestyramine resin, mineral oil and oral anticoagu- lants. Scurvy causes im- pairment of wound healing and is manifested early on by anorexia, weakness and joint and muscle aches. Name Address Phone Medical Mutual Insurance Company of Nort I Carolina and Medical Insurance Agency, 222 N Person Street, RO. Nance 411 Bulletin Board Continuing Medical Education ^ 413 New Members 414 Letters to the Editor 415 Classified Advertisements 42 1 Index to Advertisers 424 June 1984. The federal clin- ics served 9,165 or 76.3% of these encounters compared with 2,838 or 23.7% at state clinics. Reported referrals were 1 ,636 from the TCCHC federal clinic, 31.7% of its outpatient encounters, and more than 923 for state clinics, 32.5% of their outpatient encounters.

Her serum growth hormone levels were markedly elevated and her serum somatomedin-C, the GH dependent peptide that is believed to mediate the growth promoting actions of GH, was nearly 10 times normal. Although it was synthesized in 1877 and first used ther- apeutically in 1893. Retinol is also available in carrots, squash, and dark leafy vegetables. S., vitamin A deficiency occurs more often from on inability to absorb fat properly thon from a defi- cient diet. recommended doily allowance for vitamin A in adults is 5,000 I. Doses of vitamin A required to attain these benefits, however, ore also high enough to cause toxicity. Patients who feel they need additional vitamin D should seek the advice of their physician or pharmacist. Although the biochem- ical function of vitamin E is still un- clear, it is thought to protect vitol membranes from oxidative damage. Very few of the over-the-counter vitamin preparations contain vitamin K. Bleeding into the skin, mus- cles, joints, gastrointestinal mucosa, and major organs can also occur. In infants, ascorbic acid deficiency may cause retarded growth and development, as well as anemia and hemorrhaging. recommended daily allowance for ascorbic acid is 60 mg for adults, 40 mg for children and 35 mg for in- fants. NCMJ 355 i Financial news you have been waiting to hear!! The breakdown of these referrals into inpatient hospitaliza- tion, outpatient referral, and dental referrals is shown in table 3.

Within hours following its removal there was a dramatic fall in serum GH concentrations. We give, when indicated, an initial dose of 20-25 mg/kg with subsequent doses of 15-20 mg/kg at 3-4 hour intervals. The adult disease equivalent to rickets is osteomalacia, on equally debilitating disease seen in patients with kidney disease, molabsorption syndromes or other endocrine problems. In addition, the actions and/or toxici- ties of several antibiotics, including the sulfa drugs, may be affected by ascorbic acid. More than 10,453 migrants were seen by nine outreach programs.